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feel worms crawling

A nurse is caring for a client who has schizophrenia and is experiencing delusions. The client states, “I can feel worms crawling through my vein. Which of the following types of delusions should the nurse document the client is experiencing!  Delusion of reference  Delusion of persecution  Somatic delusion  Erotomaniac delusion    A nurse in an emergency department is caring for a client following a domestic dispute. The client states, “Nothing seems to go right for me and probably never will. Which of the following statements should the nurse make?  a. Are you thinking about harming yourself  b. You should remove yourself from this situation now.”  c. We will help get you through this. You’ll be fine  d. What have you done to change your situation?”  A nurse is assessing a child in the emergency department. Which of the following findings places the child at greatest risk for physical abuse?  a. The child has cystic fibrosis.  b. The child has no siblings  c. The child is homeschooled.  d. The child is 10 years old    A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take?  a. Dim the lights in the client’s room  b. Provide detailed explanations to the client  c. Administer methylphenidate to the client.  d. Encourage the client to join group activities    A nurse is treating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?  a. Prepare the client for electroconvulsive therapy  b. Encourage the client to participate in family therapy  c. Set a weight gain goal of 22 kg (4.9 lb.) per week  d. Weigh the client twice per day    A nurse is caring for a client who has major depressive disorder. After discussing the treatment with his partner, the client verbally agrees to electroconvulsive therapy (ECT) but will not sign the consent form. Which of the following actions should the nurse take?  a. Inform the client about the risks of refusing ECT.  b. Proceed with preparation for ECT based on implied consent.  c. Request that the client’s partner sign the consent form.  d. Cancel the scheduled ECT procedure.    A nurse is caring for an adolescent whose family has a very rigid system of rules. Which of the following characteristics should the nurse expect  when observing the family?  a. The older children in the family take over parenting roles for younger children.  b. The family members exhibit psychosomatic manifestations.  c. The communication between family members is minimal  d. The family members make decisions based on compromise.    A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is mania and refuses the medication. Which of the following actions should the nurse manager take first?  a. Assess the need for physical restraints.  b. Stop the newly licensed nurse from administering the medication.  c. Demonstrate how to verbally deescalate the situation  d. Discuss the purpose of the medication with the client.    A nurse is assessing a client who is withdrawing from heroin. Which of the following manifestations should the nurse expect?  a. Hyperthermia  b. Slurred speech  c. Hypotension  d. Bradycardia    A nurse in the emergency department is admitting a client who has a history of alcohol use disorder. The client has a blood alcohol level of 0.24  g/dL. The nurse should anticipate a prescription for which of the following medications?  a. Acamprosate b. Disulfiram c. Naltrexone d. Chlordiazepoxide   A nurse is planning care for a client who is experiencing acute alcohol withdrawal. The nurse should anticipate that the provider will prescribe  which of the following medications for the client?  a. Diazepam  b. Buprenorphine  c. Varenicline  d. Clonidine    After assessing a client in a crisis situation, a nurse determines the client is safe. Which of the following actions should the nurse take first  a. Involve the client in planning interventions  b. Assist the client to lower his anxiety level  c. Teach the client specific coping skills to handle stressful situations  d. Help the client identity social support    A community health nurse is providing an education program about expected age-related changes for a group of older adults. Which of the following statements by a client demonstrates an understanding of the teaching?  a. should expect my libido to decrease as I age.”  b. should expect an increased risk of depression as age-  c. know that my risk for being the victim of a crime decreases as age.”  d. “I know that I am likely to be socially isolated as l age    A nurse is providing teaching for a newly licensed nurse about the constructive use of defense mechanisms. Which of the following examples should the nurse include in the teaching  a. A woman who has a health concern postpones a medical appointment until after a vacation.  b. A school age child whose mother died 2 years ago talks about her in present tense  c. A student who is upset with her teacher writes a story about an excellent student.  d. An adult who was sexually abused as a child is unable to remember the incident.    A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked  at night. Which of the following Instructions should the nurse give the client when using thought stopping technique?  a. “Ask a family member to check the locks for you at night.”  b. -Snap a rubber band on your wrist when you think about checking the locks.”  c. “Focus on abdominal breathing whenever you go to check the locks.”  d. “Keep a journal of how often you check the locks each night.”    A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as counter transference?  a. “The client is just like my brother who finally overcame his habit.  b. The client needs to accept responsibility for his substance use.”  c. “The client asked me to go on a date with him, but I refused.”  d. The client generally shares his feelings during group therapy sessions.”    A nurse in an acute care mental health facility is planning discharge care for a client who sustained a traumatic brain injury. For which of the  Following needs should the nurse collaborate with a clinical psychologist?  a. The client needs to find a place to live after discharge  b. The client needs to begin a group therapy program prior to discharge.  c. The client needs to relearn how to perform skills that require fine motor coordination  d. The client needs a prescription for medication to promote nighttime sleep while in the facility    A nurse is assessing a client who has Alzheimer’s disease. Which of the following findings should the nurse identity as the priority?  a. The client places their shoes on the wrong feet.  b. The client is unable to remember their personal history.  c. The client does not recognize their partner  d. The client engages in wandering    A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include  the plan?  a. Keep a bright light on in the client’s room at night  b. Identify and schedule alternative group activities for the client  c. Discourage the client from expressing feelin

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